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S)Q Oal:)<MC <br />SANyJOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />Ct cuirne5s grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1 Toilia, corn Vete& <br />Fo F b) -1 R ..e YV / "il 9 _. Lic. Plate # //,/ /4 / 53 ? Business Name <br />Owner/Operator Name h-- ,,,, ni /9,6, ; 3-Loi 4 -HA; <br />Business Mailing Address 352-- ? CWe 1 oR / <br />City ,5161.,1cA r>7 Stated Zip 4.9c3A04, Bus. h. 57- 6,7-7-Mt P' O 7 <br />L_iv o- y),e? / ,-_-5uulliGK , hereby state that the above information is current, true and correct to <br />the bet of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the permit holder must notify-the EHD. Failure to notify this office may result in permit <br />revocation and penalties. , ,) <br />Signature A .(4/1'ictri <br />complgl4ct tdrettif Art .11480r, <br />404 Phi •z-n FA# 002 7 93 <br />Address 2.4PLI HA> A t%) _ Bus. Phone 0201 itte 96 <br />City 1.444 hnop Zip 9_,5 .;_--zOwner/Operator RObry4V..E <br />Check all appropriate services provided: <br />lit Wastewater disposal <br />El Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br /> , hereby state that the information I have provided is current, true and <br />ti correct to the best of my knowledge and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary own hall no e EHD immediately. <br />Signature <br /> <br />Date <br /> <br />Date <br /> <br />Commissary Name L A 4-hr <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />63/Overnight parking <br />D(Electrical hook-ups <br />FirToilet and handwashing <br />E7' Potable water <br />EI'Vehicle wash <br />.54--4.1.,lianls_c„ <br />a:,:grotb .completedtby -theEKSPHEALTRiiiiidiitiiiiiiibtOictfit0047 <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in California Health & Safety Code. The above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 I www.sigov.orgiehd <br />r< ci'71/'SJno-rrOC3l